1. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Colorectal Cancer Early detection of disease Precise Staging of Disease Progression Accurate Assessment of Therapy

2. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Colorectal Cancer Over 150,000 new colorectal cancers/yr, the second most common killer after lung cancer. A Malignant transformation of a polyp TNM staging is used to plan and assess therapy Complete surgical resection is generally required for a cure Resection of limited metastatic disease yields improved survival, unlike many cancers

3. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Colorectal Cancer Indications Diagnosis Staging Restaging

4. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Diagnosing Colorectal Cancer History 54 YOF Right Upper Quadrant abdominal pain CT reveals hepatic metastases without known primary PET Findings 3 Hyper-metabolic foci in the liver and 1 in the Left Upper Quadrant Outcome Splenic flexure colon cancer and 3 liver mets resected primary mets

5. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Colorectal Cancer Diagnosis Staging Restaging

6. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Staging Colorectal Cancer History 63 YOM Large rectal cancer via pre-op evaluation CT suggest invaded lymph nodes near the primary PET Findings Rectal, multiple pelvic, right inguinal, and liver abnormalities Outcome Aggressive chemotherapy followed by pelvic XRT Followed by successful AP (rectal) and liver resection Large solitary met

7. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Pre-operative Staging of Primary Colorectal Carcinoma Study of 48 colorectal cancer patients Pre-op PET results compared to results at surgery and follow up PETCT  Liver Mets Detected88%38% 4 liver mets were detected by PET, but ignored at time of initial surgery.  Presence of mets was confirmed >3 months after surgery Abdel-Nabi Radiology 1998; 206:755.

8. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Colorectal Cancer Diagnosis Staging Restaging  Detecting recurrence  Staging recurrence  Assessing therapy

9. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Detecting Recurrence History 60 YOM Colon cancer 2 years ago Rising CEA Negative CT findings PET Findings Retroperitoneal abnormality Outcome Nodal metastasis resected to confirm PET findings Adjuvant chemotherapy

10. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Staging Recurrence History 56 YOF Rectal cancer 14 months ago Persistently elevated CEA (never really dropped) PET Findings Single liver abnormality Outcome Liver met resection No recurrence

11. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Staging Recurrence History 38 YOF Sigmoid colon cancer 6 months ago Persistent CEA elevation Pre-op work-up was negative PET Findings Single pulmonary, multiple liver and pericaval abnormalities Outcome Biopsy of lung nodule confirmed mets Chemotherapy Nodal met near the primary location

12. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Detecting Recurrence in Patients with Increasing CEA Levels Prospective study of 28 colorectal cancer patients PET was compared to 2nd look surgery results PET predicted correctly PET  Un-resectable Disease90%  Resectable Disease81% Libutti SK Ann Surg Onc 2001;8:779

13. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Why PET? Recurrent and metastatic colorectal cancer is common (35% within 2 years) Early detection of localized disease is possible with PET, when the disease is still resectable PET helps avoid surgery in patients with multi- focal and extra-hepatic metastases

14. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Colorectal Cancer PET accurately detects local, hepatic and extra- hepatic disease PET is superior to all imaging modalities in the restaging of colorectal cancer Difficult patient management problems can be solved with the unique information PET provides